Provider Demographics
NPI:1831447663
Name:DR. JORDANA MANSBACHER, LCND CLIN SCL WORKER A PROFESSIONAL CORP
Entity type:Organization
Organization Name:DR. JORDANA MANSBACHER, LCND CLIN SCL WORKER A PROFESSIONAL CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRACTITIONER
Authorized Official - Prefix:DR
Authorized Official - First Name:JORDANA
Authorized Official - Middle Name:
Authorized Official - Last Name:MANSBACHER
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD, LCSW
Authorized Official - Phone:310-301-9121
Mailing Address - Street 1:5519 S CENTINELA AVE
Mailing Address - Street 2:SUITE 105
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90066-6945
Mailing Address - Country:US
Mailing Address - Phone:310-301-9121
Mailing Address - Fax:310-390-8578
Practice Address - Street 1:5519 S CENTINELA AVE
Practice Address - Street 2:SUITE 105
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90066-6945
Practice Address - Country:US
Practice Address - Phone:310-301-9121
Practice Address - Fax:310-390-8578
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-28
Last Update Date:2012-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS215161041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASW21516Medicare UPIN